Documente Academic
Documente Profesional
Documente Cultură
Reference Number
3.5
Version
Date ratified
05.05.2010
Date issued
23.07.2010
Review date
20.05.2012
Electronic location
Corporate Policies
Surgical site marking policy and protocol Version 1. Issued: 23.07.2010 (review date May 2012)
03/07/2012
Page 1 of 8
CONTENTS
1.
2.
3.
4.
5.
6.
7.
8.
9.
Surgical site marking policy and protocol Version 1. Issued: 23.07.2010 (review date May 2012)
03/07/2012
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Surgical site marking policy and protocol Version 1. Issued: 23.07.2010 (review date May 2012)
03/07/2012
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1. INTRODUCTION
In a service as large and complex as the NHS, there will be occasions when things do not go
as planned. These include such events as wrong site, wrong procedure or wrong person
surgery.
This policy has been formulated in response to the recommendations made by the National
Patient Safety Agency (NPSA) and is designed to complement the World Health Organisation
(WHO) checklist implemented on 1 June 2009.
The policy has been formulated in response to the Department of Health publications Building a
Safer NHS, Doing less Harm and the National Patient Safety Agency publications Building a
memory: preventing harm, reducing risks and improving patient safety, and Seven Steps to
Patient Safety. However, the ultimate aim is to reduce the risk of harm to patients through
improving the safety and quality of services and the environment.
2. PURPOSE
The purpose of this policy is to clarify and inform a universally acceptable method within
Portsmouth Hospitals NHS Trust (the Trust), by which patients undergoing a surgical procedure
will have their operative site marked appropriately and accurately.
It will:
x
x
x
x
x
3. SCOPE
This policy applies to all permanent, locum, agency and bank surgeons or their deputies who
work in Portsmouth Hospitals NHS Trust, the MDHU (Portsmouth) and who are responsible for
the identification and marking of a SDWLHQWVVXUJLFDOVLWH.
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that it may not be possible to adhere to all aspects of this document. In such circumstances,
staff should take advice from their manager and all possible action must be taken to
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4. DEFINITIONS
World Health Organisation (WHO) Checklist: a checklist developed by the WHO and
collaborators at the Harvard School of Public Health, the checklist identifies key safety steps
during perioperative care that should be accomplished during every single operation no matter
the setting or type of surgery. It has been shown to significantly reduce complications and
deaths from surgery.
Time Out Section of WHO Checklist: a momentary pause taken by the team just before skin
incision in order to confirm that several essential safety checks are undertaken and involves
everyone in the team
The Director of Clinical Standards has ultimate responsibility for ensuring that appropriate
processes are in place for the safe management of surgical patients, including preoperative
marking.
Clinical Directors
Clinical Directors in each specialty have responsibility for ensuring their surgeons mark
SDWLHQWVDFFRUGLQJO\DQGFDUU\ out the instructions within this policy.
Operating Surgeon (or deputy)
It is the responsibility of the operating surgeon or deputy to mark the operative site in
accordance with this policy
Anaesthetists
Anaesthetists are responsible for marking the site of any proposed local/regional block
WHO Checklist Coordinator/practitioner
The Coordinator is responsible for ensuring that each individual patient has been marked
appropriately prior to arrival in theatre.
The Operating Theatre Team
The operating theatre team carries out the WHO Checklist has joint responsibility for ensuring
that the correct site has been identified prior to commencement of surgery.
6. PROCESS
6.1 Making the Mark
6.1.1
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location where the procedure will be performed. The patient will be involved,
awake and aware; preferably before any prescribed pre-medication is
administered
6.1.2
The mark is to be an arrow pointing to the site of the operative procedure, as close
as possible to the incision site
6.1.3
The mark is to be made with an indelible, permanent black marker pen and should
be sufficient to remain visible after skin preparation and draping; if practicable
6.1.4
The site for all procedures that involve incisions, percutaneous punctures, or
insertion of instruments must be marked taking into consideration
x
x
6.1.5
All site markings must be made in conjunction with checks made on the patientV
diagnostic imaging results i.e. X-rays, scans, electronic imaging or other
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identity band.
Other sites that may require marking, are those necessary for some other aspect of care that
directly relates to the planned, proposed procedure i.e. dual/multiple surgical sites, stoma
sites.
Surgical site marking policy and protocol Version 1. Issued: 23.07.2010 (review date May 2012)
03/07/2012
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The person who is responsible for making the mark on the patient is the Operating
Surgeon who will be performing the procedure, or his/her deputy.
6.2.2
If the deputy marks the site, that deputy must also be present during the operative
procedure.
6.2.3
In summary, the surgeon who makes the mark must be present for that specific
operation.
The exception to this is where a patient will require a stoma as a result of a
planned, elective procedure. The stoma site may be marked by the stoma nurse
specialist pre-operatively in collaboration with the surgical team.
6.2.4
6.3.2
There may also be exemption instances where the laterality of surgery needs to be
confirmed following examination under anaesthetic (EUA) or exploration.
6.3.3
Procedures that have a midline approach for specific named treatments intended
for a single specific organ i.e. caesarean section, hysterectomy or hyroidectomy,
can also be exempted from site marking.
6.3.4
6.3.5
6.3.6
For obvious wounds or lesions, site marking is not applicable if that wound or
lesion is the site of surgical intervention. However, if there are multiple wounds or
lesions and only some of them are to be treated and this decision is predetermined, then these sites must be marked as soon as possible after the
decision has been made for surgery
6.3.7
For any sites not marked, the proposed operation/procedure must be reviewed to
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This must be undertaken in conjunction with a review of all relevant documentation,
LQFOXGLQJ WKH SDWLHQWV QRWHV DSSURSULDWH FKDUWV diagnostic imaging (correctly
oriented); DQGDGRXEOHSHUVRQFKHFNRIDOOLQIRUPDWLRQ. The procedure must note
commence without this review having occurred.
lumbar. The surgical site is then marked appropriate to show either an anterior or
posterior approach with right or left being highlighted. Secondly, the exact
interspace(s) are demonstrated using standard intra-operative radiographic
marking technique. This is based on evidence published from surgery being
performed in reported cases where the patients intended for cervical procedures
had a lumbar procedure started and vice-a-versa.
6.5
6.4.2
Ophthalmic Surgery
For single eye surgery a small mark should be made either on the temple, or on
the lateral aspect of the eye between the lateral canthus and the ear, pointing to
the correct eye for treatment. The exception is for planned bilateral procedures on
both eyes (such as bilateral squint surgery), but the laterality of such procedures
should be well documented7KHPDUNLQJRIDFKLOGVKHDGIDFHPXVWEHDVVHVVHG
at the time of pre-assessment by the surgeon as to its psychological
appropriateness. If no mark is made, then the procedures referred to at 6.3.7 must
be adhered to.
6.4.3
Bilateral Treatment
Whilst this policy focuses on laterality, specific anatomical sites, levels and areas,
surgeons must consider that it is possible to perform the wrong bilateral
procedure(s). Therefore site marking for bilateral, identical, procedures but not
required. If no mark is made, then the procedures referred to at 6.3.7 must be
adhered to.
6.4.4
ENT Surgery
There may be occasions where marking the patientVVNLQWRSRLQWWRWKHFRUUHFW
site for surgery may be inappropriate e.g. bilateral tonsillectomy/adenoidectomy,
laryngectomy. In these cases 6.3.3 / 6.3.4 / 6.3.7 apply. For ENT surgical sites
where a skin incision is made on a specific side i.e. surgery on the external pinna
and tympanotomy and surgical side/site to take the graft, these should be marked
with an arrow accordingly.
6.4.5
Burr Holes
Incidents have been reported to the NPSA of wrong side burr-holes being carried
out as a result of and failure to mark the appropriate side for surgery before the
patient arrives in theatre. It is now acceptable practice to mark the side of the burrhole to be carried out in the usual manor as directed by the Royal College of
Surgeons, Neuro-anaesthesia Society and the Society of British Neurological
Surgeons.
6.4.6
Digital Surgery
Each and every digit to be operated on must have an individual arrow pointing to
and as close as possible to the respective digit.
6.4.7
STERILITY OF MARKING
Research has been carried out to ascertain whether the use of a permanent ink marker
to mark a surgical site, affects the sterility of a patients skin after it has been cleaned
with surgical preparation solution.
Surgical site marking policy and protocol Version 1. Issued: 23.07.2010 (review date May 2012)
03/07/2012
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The results showed that no growth was seen in the cultures of swabs taken on both the
control group (un-marked) and on the experimental group (marked). Pre-operative
marking of surgical sites in accordance with the Joint Commission protocol did not affect
the sterility of the surgical field, therefore providing support for the safety of surgical site
marking (Cronen, et al . 2005).
7. TRAINING REQUIREMENTS
Training of all surgeons and junior doctors must be carried out at their induction covering the
WHO Checklist and the guidelines for surgical site marking. This will be facilitated by the
designated clinical teams providing any new employee induction for surgical teams. This will be
directed by the specialty Clinical Director.
National patient safety Agency (NPSA) Patient safety Alert 06 Correct site surgery,
making your surgery safer (2005)
National patient safety Agency (NPSA) New Guidance for Neurosurgical Teams to
avoid wrong side Burr-holes (2008)
Cronen, G. et al. Sterility of Surgical Site Marking. Journal of Bone & Joint Surgery,
2005; 87: p.2193 2195
Responsible Lead
Lead Clinican
Theatre Link
Practitioner
Evidence
Reviewed by /
Frequency
Audit of
Theatreman
documentation
Audit of
compliance with
WHO checklist
Theatre Management
Team
Quarterly
Theatre Management
Team
Quarterly
Lead Responsible
for any Required
Actions
Senior Clinical
Manager
Clinical Directors
Senior Clinical
Manager
Clinical Directors
x Through on-going daily audit through the WHO checklist process incorporating team brief.
(The theatre staff, anaesthetist and surgeon with the theatre practitioners involved in the
checklist will monitor/facilitate this. Copies of each patients WHO checklist will be filed in their
notes and also will be inputted onto theatrman data base this all occurs daily)
Surgical site marking policy and protocol Version 1. Issued: 23.07.2010 (review date May 2012)
03/07/2012
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